Out of mind

A dying man is depressed, so he gets prescribed anti-depressants. Is this absurd? A strong dose of belief might have the same effect
November 19, 2006

It was after the man in the bed next to him died, with a grisly rattling in the night, that Tyke Tierney began to decline. Before that, he'd been tirelessly cheerful and garrulous on the ward, even when told that his lung cancer was terminal and that he had, perhaps, no more than six months to live. The youngest of seven Belfast brothers, "Tyke" had got the name before his parents found time to think of anything else. That's what he'd always been: the little guy everyone loved. His wife said he'd been behaving like a wee boy for 67 years. Till now.

Overnight, Tyke changed. He stopped flirting with the nurses, waved the physios away. Suddenly, he was bitter. It was just his luck, he said, to be last in line to all his brothers and then to die first. His wife, Angela, was distraught. She had never heard him speak like this. He'd always considered himself lucky, getting out of Belfast, doing well enough for himself, finding a nice home in Holloway. All she could think to say was that, maybe now, after all these years, he should see a priest. It didn't matter that he'd always been one of life's doubters. It was never too late.

"Aye, wouldn't that be just like me," Tyke replied. "Back of the queue for the church as well. What would I say? Forgive me, Father, it's been 50 fucking years since I went to confession." After that outburst, he barely spoke.

When Tyke's name came up at the hospital management round, a nurse suggested that he was depressed. Apart from the need for a drip, he was, medically speaking, ready to go home. The house officer duly made a note to call a psychiatrist and request an opinion.

At the nursing station, the young psychiatrist picked up Tyke's notes, feeling out of place in the bustle of a real hospital. He tried to concentrate. Low thyroid levels can be associated with depression, but Tyke's were normal. He had been prescribed some drugs commonly given to the elderly, but there were none of the likely pharmacological culprits for low mood. The man was dying. He was depressed. And why not?

It struck the psychiatrist that he was acting out a bleak medical comedy. "Mr Tierney," he imagined himself saying, "the intolerable prospect of extinction has lowered the serotonin levels in your nervous system, but we may be able to alleviate the problem with some anti-depressants. Alternatively, we could offer cognitive therapy—to help reorient some of your negative beliefs. Would you like that?"

Tyke was asleep when the young psychiatrist approached bed 17. As he drew the curtains, he noticed a bottle of orange squash on the bedside table. Next to it was a new bible with some juice stains on the jacket. It looked unopened. As he pulled up a chair, Tyke woke up, his eyes cloudy. "Are you the priest?" he asked blearily.

"No, Mr Tierney, I'm a psychiatrist. Your doctors wanted me to come and have a chat with you."

"Oh, that's OK," Tyke said. "I thought Angie might have found one behind my back; got last rites in early. Very organised, my wife."

"I take it you're not a believer?"

"It's not that," Tyke said. "I just never gave it much thought."

Tyke said he felt guilty for being a burden to his wife. He gave no indication of being preoccupied about his own death, but repeatedly returned to the subject of the man who'd passed away in the bed next door. "Terrible noise, like someone was pulling the man out through his own throat. I saw him being wheeled out at three in the morning. They'd filled his bed again by lunchtime."

The psychiatrist went to call Tyke's wife, to assess a bit of "collateral history." Her husband had never been a heavy drinker, she said. Their life hadn't always been easy, but no worse than anyone else's. Whatever Tyke's faults, he had usually made up for them with his optimism. Mrs Tierney's Belfast accent became more pronounced as she told him what she thought the real problem was. Tyke had not had any strong views about the Troubles, even though some of his brothers had been involved in the republican movement. He'd also avoided religious talk, she said. "But he worried his head about it just the same, and now it's killing him as surely as the cancer."

The young psychiatrist put down the phone and turned mechanically to the drug chart. He prescribed 20mg of Citalopram. An uptake of serotonin to replace a deficiency of belief? The man still had a bit of time left. If he was depressed, let him have an anti-depressant. That would be psychiatry's parting gift to a man on the last leg of his journey. Would a priest have done any better? He doubted it. The young psychiatrist was no more able to credit that idea than Tyke had been.

An older doctor approached, briskly asking to look at the notes. It was one of the palliative care physicians. He'd also been asked for an opinion. How many opinions constitute a belief, the young psychiatrist wondered facetiously. He mentioned his conversations with Tyke and his wife. The older doctor nodded and smiled. "I don't know much about psychiatry," he said, "but it's interesting, the effect belief has on people when they're dying. Or unbelief. The religious ones and the atheists generally seem to do all right. But the people who can't make up their minds—the agnostics—they're the ones who really suffer."